MSLP : Maxillary sinus lift procedures ppt

Maxillary sinus lift procedure

1. MAXILLARY SINUS AUGMENTATION Dr . Nihal Abbas,PGT2,Dept of Periodontology,KVGDCH

2. CONTENTS Introduction History Anatomy of the maxillary sinus Graft materials General indications and Contraindications for sinus floor elevation Lateral sinus floor elevation Trans crestal sinus floor elevation Alternative techniques in crestal approach sinus elevation Newer approaches Management of complications Conclusion

3. INTRODUCTION Placement of implants in maxilla is frequently compromised or impossible due to – Atrophy of the alveolar process, – Poor bone quality, – Maxillary sinus pneumatization . Treatment of choice is influenced by – The vertical height of the residual alveolar bone, – Local intra sinus anatomy – Number of teeth to be replaced. The sinus lift is one of the most common procedures performed to increase the height of posterior maxilla for placement of dental implants Newman MG, Takei H, Klokkevold PR, Carranza FA. Carranza's clinical periodontology. Elsevier health sciences; 2011 Feb 14.

4. Maxillary sinus floor augmentation is a surgical procedure which aims to increase the amount of bone in the posterior maxilla(upper jaw bone), in the area of the premolar and molar teeth, by lifting the lower  Schneiderian membrane   (sinus membrane) and placing a bone graft . The purpose of the procedure is usually to create an increased alveolar height  to facilitate  placement of a dental implant. sinus lift. (n.d.) Farlex Partner Medical Dictionary. (2012). Retrieved July 19 2020 from  https ://medical-dictionary.thefreedictionary.com/sinus+lift

5. HISTORY AND RATIONALE When a maxillary molar or premolar is lost, the floor of the maxillary sinus expands, which further diminishes the thickness of the underlying bone. This leads to a loss in volume of bone that is available for dental implants, which rely on osseointegration to replace missing teeth. The goal of the sinus lift is to graft extra bone into the maxillary sinus, so more bone is available to support a dental implant.

6. ANATOMY OF THE MAXILLARY SINUS The pyramid-shaped  maxillary sinus  (or  antrum  of  Highmore ) is the largest of the  paranasal sinuses Located in the body of maxilla Roof : floor of orbit Floor : alveolar bone and palatine process Anterior wall : facial surface of maxilla Posterior wall : infratemporal surface Medial wall : lateral wall of nasal cavity 7 Newman MG, Takei H, Klokkevold PR, Carranza FA. Carranza's clinical periodontology

7. SCHNEIDERIAN MEMBRANE The four sinus cavities are all lined with pseudostratified, ciliated, columnar epithelium overlying a layer of periosteum in contact with the bony sinus walls. The  Schneiderian membrane  is the membranous lining of the maxillary sinus cavity. Newman MG, Takei H, Klokkevold PR, Carranza FA. Carranza's clinical periodontology. Elsevier health sciences; 2011 Feb 14.

8. The membrane connects to, the nasal epithelium through the ostium in the middle meatus; and has a thickness of approximately 0.8 mm. Adequate manipulation of the membrane and placement of graft material are possible without impeding the drainage of the sinus. The size of the sinus increases with age if the area is edentulous. The extent of pneumatization varies from person to person and from side to side. Newman MG, Takei H, Klokkevold PR, Carranza FA. Carranza's clinical periodontology. Elsevier health sciences; 2011 Feb 14.

9. INDICATIONS FOR SINUS FLOOR ELEVATION Less than 4-6 mm of vertical residual bone height in the posterior segment of the maxilla is an indication for a sinus augmentation procedure Oro-antral fistula treatment Reconstruction of palate clefts Inter positional graft with Le Fort I fractures No history of any pathology In the past, a major sinus disease has not been passed Starch-Jensen T, Aludden H, Hallman M, Dahlin C, Christensen AE, Mordenfeld A. A systematic review and metaanalysis of long-term studies (five or more years) assessing maxillary sinus floor augmentation. Int J Oral Maxillofac Surg. 2017 May 22. [Medline: 28545806] [doi: 10.1016/j.ijom.2017.05.001] .

10. CONTRAINDICATIONS Maxillary sinus infections and pathological lesions Chronic sinusitis Alveolar scar possibility Odontogenic infections Allergic rhinitis The presence of an irregular alveolar crest Starch-Jensen T, Aludden H, Hallman M, Dahlin C, Christensen AE, Mordenfeld A. A systematic review and metaanalysis of long-term studies (five or more years) assessing maxillary sinus floor augmentation. Int J Oral Maxillofac Surg. 2017 May 22. [Medline: 28545806] [doi: 10.1016/j.ijom.2017.05.001] .

11. BONE GRAFT MATERIALS AND BARRIER MEMBRANE The gold standard for grafting in sinus lift procedures has been the autogenous bone from the iliac crest or oral cavity. Allografts: FDBA / DFDBA , resorbable and non-resorbable hydroxyapatite, Xenografts: Anorganic bovine bone-derived mineral(ABBM) (Bio-Oss) Combination of graft material can also be done to enhance the quality of the bone formed. Incorporating xenografts slows down the resorption rate compared with allografts. A recent study has shown the addition of rhBMP-2/ACS to bio-Oss has a negative effect on bone formation Kao dW, Kubota A, Nevins M, Fiorellini JP. the negative effect of combining rhbMP-2 and bio-Oss on bone formation for maxillary sinus augmentation. Int J Periodontics Restorative Dent 32 (2012):61–67.

12. SINUS LIFT PROCEDURES Sinus augmentation surgery can be done from four different regions to the sinus area: Superior-lateral wall (Caldwell-Luc) Mid-lateral wall Direct method/external. Inferior-lateral wall/Lateral window sinus lift Crestal osteotomy (closed technique/internal lifting) The most commonly used methods are the inferior-lateral wall and closed sinus lifting methods. Indirect method/internal Fugazzotto PA. Augmentation of the posterior maxilla: a proposed hierarchy of treatment selection. J Periodontal 74 (2003):1682–1691.

13. Fugazzotto PA. Augmentation of the posterior maxilla: a proposed hierarchy of treatment selection. J Periodontal 74 (2003):1682–1691.

14. DIRECT SINUS LIFT METHOD The direct sinus lift or the lateral window sinus elevation is a widely used technique. BENEFITS: Direct visualization of sinus. I mplant placement and addition of the bone graft are under direct vision. Highly predictable technique Immediate placement of implant reduces healing times and eliminates the need for an additional surgical procedure Successful regeneration of bone can be expected for placement of the implant. Caldwell-Luc, Inferior-lateral wall/Lateral window sinus lift, Antral balloon sinus lift procedure Starch-Jensen T, Aludden H, Hallman M, Dahlin C, Christensen AE, Mordenfeld A. A systematic review and metaanalysis of long-term studies (five or more years) assessing maxillary sinus floor augmentation. Int J Oral Maxillofac Surg. 2017 May 22. [Medline: 28545806] [doi: 10.1016/j.ijom.2017.05.001] .

15. LATERAL WINDOW APPROACH Also, called external sinus lifting. The lateral window technique is probably the most effective and efficient way to access the maxillary sinus for bone augmentation. In this procedure, an opening into the maxillary sinus is created in the lateral wall to elevate the s chneiderian membrane and to place bone graft in the space immediately superior to the existing alveolar bone.. Starch-Jensen T, Aludden H, Hallman M, Dahlin C, Christensen AE, Mordenfeld A. A systematic review and metaanalysis of long-term studies (five or more years) assessing maxillary sinus floor augmentation. Int J Oral Maxillofac Surg. 2017 May 22. [Medline: 28545806] [doi: 10.1016/j.ijom.2017.05.001] .

16. FLAP DESIGN A bevel horizontal incision (at 1–2 mm palatal to the alveolar crest and at least 4–6 mm away from the estimated border of the hard tissue outline “window”) Buccal vertical releasing incisions are placed. Full-thickness buccal flap is reflected. Starch-Jensen T, Aludden H, Hallman M, Dahlin C, Christensen AE, Mordenfeld A. A systematic review and metaanalysis of long-term studies (five or more years) assessing maxillary sinus floor augmentation. Int J Oral Maxillofac Surg. 2017 May 22. [Medline: 28545806] [doi: 10.1016/j.ijom.2017.05.001] .

17. OUTLINE OF THE BONY WINDOW Window outline is prepared on the lateral aspect of the buccal alveolus. Size of the window is determined by the area to be grafted. Osteotomy (window) can be oval or rectangular. Inferior hard tissue outline of the window 3–5 mm above the sinus floor. Size of the upper window - determined by length of the implant. Mesial border can be extended as far as distal to canine, and the distal border - tuberosity Starch-Jensen T, Aludden H, Hallman M, Dahlin C, Christensen AE, Mordenfeld A. A systematic review and metaanalysis of long-term studies (five or more years) assessing maxillary sinus floor augmentation. Int J Oral Maxillofac Surg. 2017 May 22. [Medline: 28545806] [doi: 10.1016/j.ijom.2017.05.001] .

18. PREPARATION OF THE BONY WINDOW The lateral wall osteotomy can be prepared with a high-speed drill (carbide or diamond) or a piezoelectric bone surgery device. No. 4, 6, or 8 diamond round bur with copious saline irrigation is utilized to prepare outline of window. The osteotomy is deepened in smooth, light sweeping motion. Starch-Jensen T, Aludden H, Hallman M, Dahlin C, Christensen AE, Mordenfeld A. A systematic review and metaanalysis of long-term studies (five or more years) assessing maxillary sinus floor augmentation. Int J Oral Maxillofac Surg. 2017 May 22. [Medline: 28545806] [doi: 10.1016/j.ijom.2017.05.001] .

19. HANDLING THE BONE ISLAND 2 techniques to handle “remaining bone island” Infracture technique Wall-off technique Ting M, Rice JG, Braid SM, Lee CYS, Suzuki JB. Maxillary Sinus Augmentation for Dental Implant Rehabilitation of theEdentulous Ridge: A Comprehensive Overview of Systematic Reviews. Implant Dent. 2017 Jun;26(3):438-64.

20. ELEVATION OF SINUS MEMBRANE Small instruments (e.g., De Marco curette) are introduced along the inferior, anterior, posterior, and superior aspects of the prepared window. Larger instruments (e.g., Gracey curette) are gently introduced along the bone to continue lifting the membrane to the desired levels of height, width, and depth . 23 Starch-Jensen T, Aludden H, Hallman M, Dahlin C, Christensen AE, Mordenfeld A. A systematic review and metaanalysis of long-term studies (five or more years) assessing maxillary sinus floor augmentation. Int J Oral Maxillofac Surg. 2017 May 22. [Medline: 28545806] [doi: 10.1016/j.ijom.2017.05.001] .

21. SINUS MEMBRANE SEPARATOR A Sinus membrane separator is inserted into the frame of the window and is used to separate the Schneiderian membrane. With the help of this we can start elevating the membrane internally (for up to 2 mm around the margins of the window). Separation reduces membrane tension and results in membrane mobility, and at this point the membrane can be manually lifted. Starch-Jensen T, Aludden H, Hallman M, Dahlin C, Christensen AE, Mordenfeld A. A systematic review and metaanalysis of long-term studies (five or more years) assessing maxillary sinus floor augmentation. Int J Oral Maxillofac Surg. 2017 May 22. [Medline: 28545806] [doi: 10.1016/j.ijom.2017.05.001] .

22. BONE GRAFT AND IMPLANT PLACEMENT Ting M, Rice JG, Braid SM, Lee CYS, Suzuki JB. Maxillary Sinus Augmentation for Dental Implant Rehabilitation of theEdentulous Ridge: A Comprehensive Overview of Systematic Reviews. Implant Dent. 2017 Jun;26(3):438-64.

23. CLINICAL & RADIOGRAPHIC OUTCOME Long-term implant treatment outcome concluded that maxillary sinus floor augmentation with autogenous bone graft, mixture or bone substitutes is highly predictable and successful and also enhance the vertical alveolar bone height Autogenous bone graft resulted in the highest amount of newly formed bone comparison to various bone substitutes. Uneventful healing periods. Bone-to-implant contact was significantly higher when combination of autogenous bone graft and DBBM was used. Starch-Jensen T, Aludden H, Hallman M, Dahlin C, Christensen AE, Mordenfeld A. A systematic review and metaanalysis of long-term studies (five or more years) assessing maxillary sinus floor augmentation. Int J Oral Maxillofac Surg. 2017 May 22. [Medline: 28545806] [doi: 10.1016/j.ijom.2017.05.001] . Ting M, Rice JG, Braid SM, Lee CYS, Suzuki JB. Maxillary Sinus Augmentation for Dental Implant Rehabilitation of theEdentulous Ridge: A Comprehensive Overview of Systematic Reviews. Implant Dent. 2017 Jun;26(3):438-64.

24. COMPLICATIONS Perforation of the Schneiderian membrane is most common. A higher prevalence for sinusitis is reported in cases of membrane perforation Presence of sinus septa and a residual bone height less than 3.5 mm increases the risk for a sinus membrane perforation. Schwarz L, Schiebel V, Hof M, Ulm C, Watzek G, Pommer B. Risk Factors of Membrane Perforation and Postoperative Complications in Sinus Floor Elevation Surgery: Review of 407 Augmentation Procedures. J Oral Maxillofac Surg. 2015 Jul;73(7):1275-82.

25. LATERAL WINDOW TECHNIQUE WITHOUT A GRAFT MATERIAL FOR IMMEDIATE IMPLANT PLACEMENT Introduced by Lundgren et al 2004 . Requires sufficient vertical height to achieve primary implant stability, since immediate implant installation is necessary to preserve and support the elevated s chneiderian membrane. Allows coagulum formation a round the exposed implant surface in the sinus cavity. Implant survival rate beyond 90%. Cricchio G, Sennerby L, Lundgren S. Sinus bone formation and implant survival after sinus membrane elevation and implant placement: a 1- to 6-year follow-up study. Clin Oral Implants Res. 2011 Oct;22(10):1200-12.

26. COMPLICATIONS A higher risk of sinus membrane perforation has been reported Implant loss has been reported in a case with a perforation of the sinus membrane. Postoperative infection. Exposure of the covering membrane, Swelling, Mild postoperative oedema, Pain, Loosening of healing abutments, Nose bleeding Cricchio G, Sennerby L, Lundgren S. Sinus bone formation and implant survival after sinus membrane elevation and implant placement: a 1- to 6-year follow-up study. Clin Oral Implants Res. 2011 Oct;22(10):1200-12.

27. INDIRECT SINUS LIFT METHOD The osteotome sinus floor elevation technique or crestal approach which is also called the indirect sinus lift procedure. Invented by Summer in 1994 ADVANTAGES Minimally invasive Surgical techniq ue Most suitable for installation of a single implant Damage to the sinus is minimal without affecting the sinus pressure Vertical height of the bone is enough to stabilize the implant Simplicity of the procedure requires less time and expertise. DISADVANTAGES Blind procedure More chances of errors. Implant loading is recommended after 3 months . Starch-Jensen T, Aludden H, Hallman M, Dahlin C, Christensen AE, Mordenfeld A. A systematic review and metaanalysis of long-term studies (five or more years) assessing maxillary sinus floor augmentation. Int J Oral Maxillofac Surg. 2017 May 22. [Medline: 28545806] [doi: 10.1016/j.ijom.2017.05.001] .

28. CRESTAL OSTEOTOMY TECHNIQUE Trans crestal sinus floor elevation/ Trans alveolar Osteotome/ Osteotome Sinus Floor Elevation (OSFE) technique Considered to be a conservative approach to sinus elevation, but it is also a “blind” technique. It is a technique-sensitive procedure. The osteotome technique is a procedure that uses osteotomes to compress bone against the floor of the sinus, ultimately leading to a controlled “inward fracture” of the sinus floor bone along with the Schneiderian membrane, creating a “tented” space for grafting. Indicated in cases with moderate bone height (e.g., 7–9 mm) that require limited sinus bone augmentation. Pjetursson BE, Ignjatovic D, Matuliene G, Brägger U, S chmidlin K, Lang NP. Maxillary sinus floor elevation using the osteome technique with or without grafting material. Part II – Radiographic tissue remodeling. Clin Oral Implants Res. 2009 Jul:20(7):677-83

29. PROCEDURE An osteotomy site is prepared with a series of drills to a depth that is approximately 1 to 2 mm below the floor of the maxillary sinus. Using a 2 mm cylindrical bur, the implant site - prepared depth 1 mm below the sinus floor. A periapical radiograph is taken with the 2 mm guide pin in place. Osteotomy enlarged 3 mm cylindrical drill to the desired depth. Before any attempts to elevate, graft material is added to the osteotomy- volume of material should not exceed 2–3 mm in height Osteotomes are used to increase compressive forces gradually against the floor of the sinus by adding incremental quantities of graft material until the floor of the sinus fractures inward. A 3 mm osteotome is inserted into the osteotomy and advanced with light malleting. Pjetursson BE, Ignjatovic D, Matuliene G, Brägger U, S chmidlin K, Lang NP. Maxillary sinus floor elevation using the osteome technique with or without grafting material. Part II – Radiographic tissue remodeling. Clin Oral Implants Res. 2009 Jul:20(7):677-83

30. After the controlled inward fracture of the maxillary sinus floor, bone graft materials continue to be slowly introduced, into the maxillary sinus. This leads to elevation of the membrane and thus allows a vertical expansion of the bone height in a localized area of the maxillary sinus. Once the sinus membrane is elevated with bone graft to the desired height, the implant osteotomy can be completed. The final implant osteotomy drill is used to finish preparing the lateral walls and the implant is inserted. Additional graft material should be added to the osteotomy prior to implant placement. Multiple individual sites can be elevated and prepared simultaneously through separate osteotomy sites. Pjetursson BE, Ignjatovic D, Matuliene G, Brägger U, S chmidlin K, Lang NP. Maxillary sinus floor elevation using the osteome technique with or without grafting material. Part II – Radiographic tissue remodeling. Clin Oral Implants Res. 2009 Jul:20(7):677-83

31. ABSOLUTE CONTRAINDICATION: Previous sinus surgery like the Caldwell Luc operation. Maxillary sinus diseases such as tumors or Chronic sinusitis, strong allergic conditions RELATIVE CONTRAINDICATIONS: Sinuses that have an acutely sloped floor Septa in the location of the planned osteotomy. P resence of Underwood’s septa or severe sinus floor convolutions. DRAWBACKS OF THE TECHNIQUE Procedure involves repeated tapping of osteotomes with a mallet to create the necessary pressure to fracture the floor of the maxillary sinus. Postoperative complication, called benign paroxysmal positional vertigo (BPPV), has been associated with the osteotome sinus elevation technique. Pjetursson BE, Ignjatovic D, Matuliene G, Brägger U, S chmidlin K, Lang NP. Maxillary sinus floor elevation using the osteome technique with or without grafting material. Part II – Radiographic tissue remodeling. Clin Oral Implants Res. 2009 Jul:20(7):677-83

32. CLINICAL & RADIOLOGICAL OUTCOME Overall implant survival rate higher than 90%. The implant survival rate - higher when the residual vertical alveolar bone height is more than 5 mm. Installation of short implants (≤ 6 mm) in conjunction with osteotome-mediated sinus floor elevation significantly diminished the implant survival rate. Osteotome-mediated sinus floor elevation with a graft material and simultaneous installation of implants seem to facilitate more vertical alveolar bone gain compared to the use of no graft material. Bone formation was more pronounced during first year and tends to increase for three years. Pjetursson BE, Ignjatovic D, Matuliene G, Brägger U, Schmidlin K, Lang NP. Maxillary sinus floor elevation using the osteome technique with or without grafting material. Part II – Radiographic tissue remodeling. Clin Oral Implants Res. 2009 Jul:20(7):677-83

33. COMPLICATIONS Perforation of the Schneiderian membrane with a mean incidence of 3.8%. Presence of sloped maxillary sinus floor, sinus septa and root apices penetrating into the maxillary sinus increases the risk. P ostoperative bleeding. P ostoperative infection, Disorientated after surgery, Nose bleeding, or blocked nose, Hematomas, Benign paroxysmal positional vertigo. Tan WC, Lang NP, Zwahlen M, Pjetursson BE. A systematic review of the success of sinus floor elevation and survival of implants inserted in combination with sinus floor elevation. Part II: transalveolar technique. J Clin Periodontol. 2008 Sep:35(8 Suppl): 241-54

34. ALTERNATIVE TECHNIQUES IN CRESTAL APPROACH SINUS ELEVATION SINUS LIFT BY DILATATION Using the elasticity of the bone, Summers started dilation of sinus floor, thus increasing the length of his implants. The disadvantages of this technique are its limited indications - the height lack of 1-2 mm and the absence of direct vision of the membrane. Often results in membrane tear if not careful. Abadzhiev, M. (2009) Alternative Sinus Lift Techniques Literature Review. Journal of IMAB, 16, 23-27.

35. 2 . SUMMERS’ OSTEOTOME TECHNIQUE Summers developed t his technique, using the fractured sinus floor as an osteotome and putting the grafting material through the osteotome hole. 3. MODIFIED SUMMERS TECHNIQUE Summers’ technique was modified and the original concave, cutting osteotomes were replaced by convex and rounded ones. The rounded osteotomes permit safe expansion of the hole and pushes the graft into the sinus cavity. Abadzhiev, M. (2009) Alternative Sinus Lift Techniques Literature Review. Journal of IMAB, 16, 23-27.

36. ADVANCED SURGICAL TECHNIQUES The Summer’s inflated sinus balloon was designed to lift the Schneiderian membrane gently and uniformly. First described by SUMMERS in 1994. ADVANTAGES- Can be done in presence of 3mm or more residual bone. The balloon instrument can also be used to anticipate the required bone graft material. Kfir E, Kfir V, Eliav E, Kaluski E. Minimally invasive antral membrane balloon elevation: report of 36 procedures. J Periodontol. 2007;78:2032-5 .

37. PROCEDURE Step 1 : the initial osteotomy is performed to a depth of about 1–2 mm blow the floor of the sinus cavity Kfir E, Kfir V, Eliav E, Kaluski E. Minimally invasive antral membrane balloon elevation: report of 36 procedures. J Periodontol. 2007;78:2032-5 .

38. Step 2 : to insert the sinus lift balloon Step 3 : to detach the sinus membrane On average with 1 cc of saline the sinus lift balloon may elevate the sinus membrane 6 mm. Kfir E, Kfir V, Eliav E, Kaluski E. Minimally invasive antral membrane balloon elevation: report of 36 procedures. J Periodontol. 2007;78:2032-5 .

39. Step 4 : bone grafting material placement Step 5 : dental implant placement Kfir E, Kfir V, Eliav E, Kaluski E. Minimally invasive antral membrane balloon elevation: report of 36 procedures. J Periodontol. 2007;78:2032-5 .

40. THE HYDROPNEUMATIC SINUS LIFT A crestal access technique, introduced in 2008 by Troedhan, A. Kurrek, M.Wainwright Also, called the Hydraulic sinus lift. Hydraulic pressure is applied into the osteotomy site by means of air/water exhaust spray from handpiece or a water jet to detach the Schneiderian membrane -loosen the membrane. After the osteotomy with the pilot bur, reaching 2 mm from the sinus cavity, the hole is expanded to the sinus floor using calibrated diamond tips Using a tip, called “Trumpet” , a cooling solution is inserted from the piezo surgery unit and its hydrodynamic pressure pushes the Schneiderian membrane and detaches it from the floor. Chen L, Cha J. An 8-year retrospective study: 1,100 patients receiving 1,557 implants using the minimally invasive hydraulic sinus condensing technique. J Periodontol 76 (2005):482–491.

41. GENERAL COMPLICATIONS AND ITS MANAGEMENT ANTRAL PSEUDOCYSTS C an be thoroughly drained once the osteotomy has been prepared and before membrane elevation and graft placement. SINUSITIS If dentally related, the source of such infections should be removed and an antibiotic should be initiated. PERFORATION OF SCHNIDERIAN MEMBRANE – Small perforations can be repaired by placing a resorbable collagen membrane over the perforated area after it has been elevated and before the addition of bone graft. Schwarz L, Schiebel V, Hof M, Ulm C, Watzek G, Pommer B. Risk Factors of Membrane Perforation and Postoperative Complications in Sinus Floor Elevation Surgery: Review of 407 Augmentation Procedures. J Oral Maxillofac Surg. 2015 Jul;73(7):1275-82.

42. Larger perforations are usually repaired using larger resorbable membranes fixed to the superior aspect of the osteotomy window with bone tacks before bone augmentation. INTRAOPERATIVE BLEEDING: It can be controlled by placement of the bone graft, which exerts pressure on the wound . Schwarz L, Schiebel V, Hof M, Ulm C, Watzek G, Pommer B. Risk Factors of Membrane Perforation and Postoperative Complications in Sinus Floor Elevation Surgery: Review of 407 Augmentation Procedures. J Oral Maxillofac Surg. 2015 Jul;73(7):1275-82.

43. POSTOPERATIVE BLEEDING Sometimes occur in the form of a nose bleed. Patients should be advised of this possibility and be instructed not to blow their nose for at least 5 days after the surgery. POSTOPERATIVE SWELLING AND HEMATOMA An NSAID is highly recommended. POSTOPERATIVE INFECTIONS Use of appropriate antibiotics before and after the surgical procedure is standard and may reduce infection risk. If antibiotic therapy is not effective, incision and drainage should be performed. If the infection cannot be resolved, then a mucoperiosteal flap should be raised, the graft removed and the site thoroughly irrigated. Schwarz L, Schiebel V, Hof M, Ulm C, Watzek G, Pommer B. Risk Factors of Membrane Perforation and Postoperative Complications in Sinus Floor Elevation Surgery: Review of 407 Augmentation Procedures. J Oral Maxillofac Surg. 2015 Jul;73(7):1275-82.

44. CONCLUSION In the posterior maxillary region, the vertical bone height is often insufficient to receive an implant.  For more than 30 years, sinus elevation has been the gold standard for increasing the vertical height of edentulous ridges in the posterior regions of the maxilla. The surgical approach may be performed either laterally or from the crest. The choice of technique will largely depend on the characteristics of the edentulous site, which will either allow or prevent placement of implants simultaneous to the augmentation procedure. The elevation of the sinus membrane allows the placement of a filling material which may be autogenous bone, allografts or xenografts. 

45. It is suggested that the osteotome technique should be considered as an alternative for the lateral window technique, especially in cases in which a septum exists in the sinus or there is a single tooth restoration in the posterior maxilla, where there is a high risk of membrane perforation due to limited access for window preparation. Although there are some contraindications to both the procedures, there are almost no absolute contraindications. With experience, maxillary sinus floor elevation is a procedure that greatly benefits the patient, with a predictable outcome.

46. REFERENCES Newman MG, Takei H, Klokkevold PR, Carranza FA. Carranza's clinical periodontology. Elsevier health sciences; 2011 Feb 14. sinus lift. (n.d.) Farlex Partner Medical Dictionary. (2012). Retrieved July 19 2020 from  https://medical-dictionary.thefreedictionary.com/sinus+lift Kao dW, Kubota A, Nevins M, Fiorellini JP. the negative effect of combining rhbMP-2 and bio-Oss on bone formation for maxillary sinus augmentation. Int J Periodontics Restorative Dent 32 (2012):61–67. Fugazzotto PA. Augmentation of the posterior maxilla: a proposed hierarchy of treatment selection. J Periodontal 74 (2003):1682–1691. Starch-Jensen T, Aludden H, Hallman M, Dahlin C, Christensen AE, Mordenfeld A. A systematic review and metaanalysis of long-term studies (five or more years) assessing maxillary sinus floor augmentation. Int J Oral Maxillofac Surg. 2017 May 22. [Medline: 28545806] [doi: 10.1016/j.ijom.2017.05.001] . Ting M, Rice JG, Braid SM, Lee CYS, Suzuki JB. Maxillary Sinus Augmentation for Dental Implant Rehabilitation of theEdentulous Ridge: A Comprehensive Overview of Systematic Reviews. Implant Dent. 2017 Jun;26(3):438-64.

47. REFERENCES Schwarz L, Schiebel V, Hof M, Ulm C, Watzek G, Pommer B. Risk Factors of Membrane Perforation and Postoperative Complications in Sinus Floor Elevation Surgery: Review of 407 Augmentation Procedures. J Oral Maxillofac Surg. 2015 Jul;73(7):1275-82. Cricchio G, Sennerby L, Lundgren S. Sinus bone formation and implant survival after sinus membrane elevation and implant placement: a 1- to 6-year follow-up study. Clin Oral Implants Res. 2011 Oct;22(10):1200-12. Pjetursson BE, Ignjatovic D, Matuliene G, Brägger U, Schmidlin K, Lang NP. Maxillary sinus floor elevation using the osteome technique with or without grafting material. Part II – Radiographic tissue remodeling. Clin Oral Implants Res. 2009 Jul:20(7):677-83 Kfir E, Kfir V, Eliav E, Kaluski E. Minimally invasive antral membrane balloon elevation: report of 36 procedures. J Periodontol. 2007;78:2032-5. Chen L, Cha J. An 8-year retrospective study: 1,100 patients receiving 1,557 implants using the minimally invasive hydraulic sinus condensing technique. J Periodontol 76 (2005):482–491

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